Mental health among commando, airborne and other UK infantry personnel

 
Occupational Medicine 2010;60:552–559
                                                                                                      Advance Access publication on 5 September 2010 doi:10.1093/occmed/kqq129

Mental health among commando, airborne and
other UK infantry personnel
J. Sundin1, N. Jones1, N. Greenberg1, R. J. Rona2, M. Hotopf2, S. Wessely2 and N. T. Fear1
1
 Academic Centre for Defence Mental Health, Department of Psychological Medicine, Institute of Psychiatry, King’s College
London, London SE5 9RJ, UK, 2King’s Centre for Military Health Research, Department of Psychological Medicine, Institute of
Psychiatry, King’s College London, London SE5 9RJ, UK.
Correspondence to: J. Sundin, Academic Centre for Defence Mental Health, King’s College London, Weston Education Centre, 10
Cutcombe Road, London SE5 9RJ, UK. Tel: 144 (0)20 7848 5344; fax: +44 (0)20 7848 5397; e-mail: Josefin.sundin@kcl.ac.uk

                                                                                                                                                                                               Downloaded from occmed.oxfordjournals.org at King's College London on December 2, 2010
         ...................................................................................................................................................................................

         Background Despite having high levels of combat exposure, commando and airborne forces may be at less risk of
                    mental ill-health than other troops.
         ...................................................................................................................................................................................

         Aims                   To examine differences in mental health outcomes and occupational risk factors between Royal Ma-
                                rines Commandos (RMCs), paratroopers (PARAs) and other army infantry (INF).
         ...................................................................................................................................................................................
         Methods                Three groups of personnel (275 RMCs, 202 PARAs and 572 INF) were generated from a UK military
                                cohort study of personnel serving at the time of the 2003 Iraq war. Participants completed a question-
                                naire about their mental health and experiences on deployment. Differences in mental health out-
                                comes between the groups were examined with logistic regression and negative binomial
                                regression analyses.
         ...................................................................................................................................................................................
         Results                Both RMCs and PARAs were less likely to have multiple physical symptoms or to be fatigued, and
                                RMCs also had lower levels of general mental health problems and lower scores on the Post-traumatic
                                Checklist than INF personnel. Differences were not explained by the level of unit cohesion.
         ...................................................................................................................................................................................

         Conclusions The effect of warfare on troops’ well-being is not universal across occupational groups. A possible
                     explanation for this difference is that the high level of preparedness in RMCs and PARAs may lessen
                     the psychological impact of war-zone deployment experiences.
         ...................................................................................................................................................................................

         Key words              Airborne forces; commando forces; marines; PTSD; UK.
         ...................................................................................................................................................................................

Introduction                                                                                          forces. Like RMCs, PARAs are highly trained to enable
                                                                                                      them to operate independently for long periods and under
Most military forces utilize commando and airborne in-                                                harsh conditions [2].
fantry troops who are subject to a more rigorous selection                                               Since commando and airborne forces are likely to be
process and undergo more arduous training compared                                                    exposed to traumatic situations more frequently, it fol-
with other infantry troops; in the UK armed forces, these                                             lows that they should be at increased risk of ill-health.
include Royal Marines Commandos (RMCs) and air-                                                       However, research does not support this view. Recent
borne forces such as paratroopers (PARAs) [1–2]. These                                                UK studies have shown that the prevalence of post-
forces often undertake more hazardous military duties,                                                traumatic stress disorder (PTSD) tends to be low in com-
such as deploying to newly established and uncertain the-                                             mando and airborne forces, such as RMCs and PARAs
atres of operations. The RMCs are the amphibious infan-                                               [3–4], but the lack of a non-commando or airborne forces
try of the UK armed forces and are a core component of                                                control group in the study by Hacker Hughes et al. [4]
the UK rapid deployment force. Their role requires them                                               limits their conclusions. Similar findings of resilience in
to be ready to deploy at short notice and they are trained                                            marines compared with army and navy personnel have
to fight in any terrain; they are the UK armed forces’ spe-                                           been reported in US studies [5–7].
cialists in cold weather and mountain warfare [1]. The                                                   The role of unit cohesion is of growing interest for
PARAs are the airborne infantry element of the British                                                studies of psychological health in military personnel. Sev-
Army; their role is to operate with minimal, or no support,                                           eral studies and meta-analyses have examined and dem-
potentially behind enemy lines and against superior                                                   onstrated a positive relation between unit cohesion and
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J. SUNDIN ET AL.: MENTAL HEALTH IN MILITARY PERSONNEL 553

performance [8]. There is also support for a relationship      two airborne support units of artillery and engineers) and
between improved well-being and readiness with higher          other INF were identified through information on parent
levels of unit cohesion, and unit cohesion may serve as        unit. N.J. (a serving member of the Defence Medical
a resilience factor for PTSD and combat stress reactions       Services) advised on the generation of these groups. Only
[3,9,10]. Recent research has also shown that there is an      regular male personnel were studied due to the small
association between unit cohesion and excessive alcohol        numbers of females and reserve personnel in the RMCs
use, with heavy drinking being associated with moderate        and PARAs groups.
to high levels of comradeship in theatre [11]. There is also       Participants provided information on socio-demographic
some evidence to suggest higher levels of individual and       and military characteristics, deployment experiences and
unit morale among US marines compared to US Army               current health. Childhood adversity was assessed as
soldiers [5].                                                  a composite score of 16 questions on childhood experien-
   This study examines differences in mental health out-       ces [14]. Information on deployment experiences in-
comes and occupational risk factors between RMCs,              cluded the area of deployment, time spent in a forward
PARAs and other army infantry (INF). We hypothesized           area and potentially adverse experiences on deployment
that RMCs and PARAs would show fewer adverse mental            (coming under small arms fire, coming under mortar

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health outcomes and higher levels of unit cohesion as          or artillery attack and seeing personnel wounded or
compared to other INF.                                         killed). Two questions assessed appraisals of deployment
                                                               experiences: thinking one might be killed and whether
                                                               work in theatre matched trade and experiences (perceived
Methods                                                        preparedness).
                                                                   Unit cohesion was conceptualized as a construct based
Data were utilized from a study of UK military personnel       on seven variables that assessed comradeship, leadership
who were in service during March 2003 and who partic-          and whether personnel felt well informed during deploy-
ipated in the first wave of a prospective cohort study         ment (Table 1). Four of the items were taken from a sec-
[12,13]. Invited participants were from a random sample        tion asking personnel about their perceptions of their
stratified by service, enlistment type (regular or reserve     deployment and were measured on a five-point scale from
personnel) and deployment status. Reserve personnel            ‘strongly disagree’ to ‘strongly agree’. The other three
were over-sampled by a ratio of 2:1. Data were collected       items were part of a question on what aspects of their de-
through postal surveys and visits to military bases. The       ployment personnel felt were most and least rewarding.
cohort comprised of 4722 personnel who had deployed            For each item, personnel had the option of ticking most
on Op TELIC 1 (the military code name for the first            rewarding, least rewarding or neither. All seven items
phase of the 2003 Iraq war) and 5550 personnel who were        were recoded on a binary scale, with the ‘neither’ category
not deployed on TELIC 1 (referred to as Era). Personnel        coded as missing.
in the Era group may have deployed on later phases of              The scale reliability was acceptable (Cronbach’s a 5
TELIC or on other major deployments.                           0.77). The unit cohesion construct was generated
    The response rate was 61%. Analysis of non-responders      through principal component analysis (PCA) of a tet-
showed that age, rank, gender, ethnic group and enlist-        rachoric correlation matrix, which is appropriate for bi-
ment type differed between responders and non-                 nary data [15]. The PCA resulted in a two-factor
responders, but there were no differences in fitness to        solution with one general factor that explained 61.0%
deploy [14]. Weighting for non-response had little effect      of the total variance. The factor loadings ranged between
on the relative risks, which indicates that bias was small.    0.47 and 0.86 and the standardized factor loadings were
    The study received approval from the Ministry of           used to generate the unit cohesion construct.
Defence (MOD) research ethics committee and the                    PTSD was measured with the 17-item National Cen-
King’s College Hospital local research ethics committee.       tre for PTSD Checklist (PCL-C) [16], with cases defined
    Analyses were made on a subsample of respondents           as those scoring $50. Due to insufficient numbers of
who had deployed on a major operation since 2000,              PTSD cases in the RMC and PARA groups, the PCL-
and who were RMCs (n 5 275), PARAs (n 5 202) or                C score was used as outcome measure in the multivariate
members of other INF regiments (n 5 572). The sample           analyses. The score was recoded from 17–85 to a range
was identified through information on Service branch           from 0–68 for the purpose of the multiple variable anal-
(i.e. Royal Navy, Royal Marines, British Army and Royal        yses. Alcohol use was measured with the alcohol use dis-
Air Force) and parent unit, obtained from the cohort           orders identification test [17], with cases defined as those
study questionnaire and from the Defence Analytical            scoring $16. Fatigue was measured with the Chalder fa-
Services Agency. RMCs were identified by their service         tigue scale [18], with cases defined as those scoring $4.
numbers and included personnel who served in a Royal           Symptoms of common mental disorder were measured
Marines infantry or support unit. PARAs (defined as per-       with the General Health Questionnaire 12 (GHQ-12)
sonnel who belonged to three airborne combat units and         [19] with cases defined as those scoring $4. Physical
554 OCCUPATIONAL MEDICINE

Table 1. Variables and response scale of the seven items included in    mental health outcome analyses were repeated on this
the unit cohesion construct                                             subsample.
Variables                                       Response scale

How much do you agree or disagree with                                  Results
the following statements:
  I felt a sense of comradeship (or             1   Strongly disagree   The groups differed on several socio-demographic
     closeness) between myself and other        2   Disagree            aspects (Table 2). Compared to the INF, PARAs were
     people in my unit.                         3   Neither             younger and had deployed for less time in the past 3 years.
  I could have gone to most people in my        4   Agree               RMCs, compared with the INF, had higher educational
     unit if I had a personal problem.          5   Strongly agree
  My seniors were interested in what I did
                                                                        attainment, were less likely to hold a rank of junior non-
     or thought.                                                        commissioned officer and had lower levels of childhood
  I felt well informed about what was                                   adversity. Compared with RMCs, PARAs were younger,
     going on.                                                          had deployed for less time in the past 3 years and reported
What if any were the three most rewarding                               more childhood adversity.

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 and three least rewarding aspects of your                                  PARAs and RMCs were more likely to have
 service on Op TELIC:                                                   deployed on any phase of TELIC compared with the
 Quality of leadership of senior chain of       1 Most rewarding        INF (Table 3). Time spent in a forward area differed be-
   command was among the three most/            2 Least rewarding
   least rewarding aspects of service.                                  tween the groups, with PARAs and RMCs more likely to
 Quality of leadership of immediate                                     spend up to a month, while the INF tended to spend no
   commanders was among the three                                       time, or more than a month, in a forward area. Preva-
   most/least rewarding aspects                                         lence of combat exposures was high in all three groups.
   of service.                                                          RMCs were more likely to have come under mortar or
 Teamwork/Comradeship was among the
   three most/least rewarding aspects                                   artillery fire and to have seen personnel wounded or
   of service.                                                          killed compared to the INF. Personnel in the INF were
                                                                        more likely to have come under small arms fire compared
                                                                        with the PARAs.
                                                                            There was no difference in levels of unit cohesion be-
symptoms were assessed with a checklist of 53 common                    tween PARAs and the INF. In contrast, RMCs had higher
symptoms, with cases defined as individuals endorsing                   levels of unit cohesion compared with the other two
$18 symptoms [12].                                                      groups.
    Socio-demographic characteristics, pre-deployment                       There were differences in length of time between leav-
and combat experiences were compared between the                        ing theatre and completing the questionnaire. While
three groups. Proportions were calculated and statistical               PARAs and INF personnel averaged .500 days between
significance was assessed with Pearson’s x2 statistic.                  leaving theatre and completing the questionnaire, RMCs
    Associations between group membership and mental                    averaged .700 days. However, time from leaving theatre
health outcomes were assessed with odds ratios (OR), cal-               to completing the questionnaire was not associated with
culated with binary logistic regression, and incidence-rate             any of the mental health outcomes for the RMCs.
ratios (IRR), calculated with negative-binomial regres-                     RMCs had lower rates of all negative mental health
sion [20]. We adjusted for variables that were related                  outcomes except alcohol use, which was comparable to
to both group membership and the mental health out-                     the rate for the INF (Table 4). Following adjustment,
comes. For all models, the socio-demographic and pre-                   PARAs had lower rates of fatigue and physical symptoms
deployment variables were fitted first followed by the                  than the INF. Low levels of unit cohesion were predictive
deployment and post-deployment risk factors. The cut-                   of all mental health outcomes but did not account for dif-
off for inclusion in the model was set at P values #0.10.               ferences between the groups. There were no differences
Differences in theatre of deployment were adjusted for                  between the RMCs and PARAs for these mental health
in all models. Goodness-of-fit was assessed with the                    outcomes (data not shown).
Hosmer–Lemeshow test [21] and fit was adequate for                          There was a significant interaction between childhood
all models.                                                             adversity and group membership on the GHQ score (INF
    We examined stress reactivity with three interaction                versus PARAs: x2(3) 5 10.26, P , 0.05), with PARAs
effects for group membership and combat exposure                        being less reactive to high levels of childhood adversity.
and also with two background factors (level of education                    The proportion of cases reporting PTSD symptoms
and childhood adversity). Differences in theatre of de-                 was similar for the INF and the PARAs. RMCs had sig-
ployment were adjusted for in all models.                               nificantly fewer cases of PTSD compared with the INF,
    A sensitivity analysis was carried out for personnel who            P , 0.05 (Fisher’s exact test), but not compared with
had deployed on a TELIC operation (n 5 874) and all                     the PARAs (not significant).
J. SUNDIN ET AL.: MENTAL HEALTH IN MILITARY PERSONNEL 555

Table 2. Socio-demographic characteristics of the INF, PARAs and RMCs

Socio-demographic and                  INF (n 5 572)a             PARAs (n 5 202)a            RMCs (n 5 275)a            INF versus        INF versus        PARAs versus
pre-deployment variables                                                                                                 PARAs             RMCs              RMCs

                                       n (%)                      n (%)                       n (%)                      P value           P value           P value

Age (years)                            29.9 (29.3–30.4)b          28.4 (27.5–29.2)b           30.4 (29.6–31.3)b          ,0.05             NS                ,0.001
Educational statusc
  No qualifications                      94   (17)                  19   (10)                  18    (7)                 NS                ,0.001            NS
  GCSE or equivalent                    289   (54)                 107   (55)                 129    (48)
  A-levels or equivalent                100   (19)                  46   (24)                  87    (32)
  Degree                                 56   (10)                  22   (11)                  37    (14)
Rank
  Other rank                            140 (25)                    66 (34)                     92 (34)                  NS                ,0.05             NS
  Junior non-                           227 (40)                    72 (37)                     85 (31)
    commissioned officer

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  Senior non-                           132 (23)                    37 (19)                     60 (22)
    commissioned officer
  Officer                                65 (12)                    22 (11)                    34 (13)
Had prior deployment                    450 (79)                   147 (73)                   211 (78)                   NS                NS                NS
  experience
Time deployed for in past
3 years
  #6 months                             148   (27)                  67   (34)                  65    (24)                ,0.05             NS                ,0.001
  7–12 months                           249   (45)                  92   (34)                 108    (40)
  .12 months                            161   (29)                  38   (19)                  95    (36)
Medically downgraded                     45   (8)                    9   (5)                   20    (7)                 NS                NS                NS
Number of childhood
  adversity factors
  0/1                                    97   (17)                  40   (20)                   57   (21)                NS                ,0.001            ,0.05
  2/3                                   146   (26)                  55   (27)                   97   (35)
  4/5                                   122   (21)                  35   (17)                   67   (24)
  $6                                    207   (36)                  72   (36)                   54   (20)

Numbers (n), percentages (%), means (M) and 95% CIs are displayed together with P values for t-tests and x2 statistics. NS 5 not significant.
a
    Some categories do not add up to denominators because of missing data.
b
    Mean and 95% CI and corresponding t-test.
c
    General Certificate of Secondary Education (GCSEs) are examinations usually taken at age 16. A-levels are usually taken at age 18 and are required for entry to university.

   The difference in PCL-C score between RMCs and                                           Discussion
the INF held after adjusting for socio-demographics,
pre-deployment factors and experiences on deployment                                        Combat exposures were common in all three groups, but
(Table 5). In contrast, after adjusting for covariates, the                                 the prevalence of mental ill-health was generally low. Our
lower rates of PCL-C scores in PARAs compared with                                          hypotheses of lower rates of psychological distress and
the INF were removed. After adjusting for covariates,                                       higher unit cohesion among RMCs and PARAs were only
RMCs also had lower PCL-C scores compared with                                              partially supported. Consistent with previous research,
the PARAs.                                                                                  RMCs reported lower levels of mental ill-health and
   There were interactions between seeing personnel                                         had higher levels of unit cohesion compared to the
wounded or killed and group membership on PCL-C                                             INF [5,6]. This was not the case for PARAs, who were
score, both for the comparison between PARAs and                                            comparable to the INF on levels of unit cohesion, general
INF (IRR 0.43, 95% CI 0.25–0.74) and for the PARAs                                          mental health problems and PCL-C scores. PARAs also
and RMCs comparison (IRR 2.66, 95% CI 1.30–5.44).                                           had higher PCL-C scores than the RMCs. In contrast,
PARAs were less stress-reactive to seeing personnel                                         both RMCs and PARAs were less likely to be fatigued
wounded or killed compared with the INF and RMCs.                                           or experience multiple physical symptoms compared with
   Replication of the analyses on only TELIC-deployed                                       the INF.
participants showed that there was no effect of TELIC                                          Interactions between group membership and seeing
deployment on the comparisons between the RMCs or                                           personnel wounded or killed on PCL-C score indicated
the PARAs with the INF or between the RMCs and                                              that PARAs were less stress-reactive to witnessing trauma
the PARAs (data available from the authors).                                                to others than both the INF and RMCs. High levels of
556 OCCUPATIONAL MEDICINE

Table 3. Deployment experiences of the INF, PARAs and RMCs

Deployment                     INF (n 5 572)a              PARAs (n 5 202)a           RMCs (n 5 275)a             INF versus INF versus PARAs versus
experiences variables                                                                                             PARAs      RMCs       RMCs

                               n (%)                       n (%)                      n (%)                       P value         P value       P value

Any TELIC               434              (76)                190 (94)                   250 (91)                  ,0.001          ,0.001        NS
  deployment
Time spent in
  a forward area
  Not at all            153              (28)                 35   (18)                  55   (20)                ,0.05           ,0.001        NS
  Up to 1 month         155              (28)                 77   (40)                 129   (48)
  .1 month              248              (45)                 81   (42)                  86   (32)
Came under small        322              (56)                 89   (44)                 146   (53)                ,0.05           NS            ,0.05
  arms fire
Came under mortar or    320              (56)                125 (62)                   181 (66)                  NS              ,0.05         NS

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  artillery fire
Saw personnel           366              (65)                133 (66)                   195 (71)                  NS              ,0.05         NS
  wounded or killed
Thought might be        383              (68)                126 (63)                   174 (64)                  NS              NS            NS
  killed
Work in theatre was      67              (15)                 30 (16)                    31 (12)                  NS              NS            NS
  generally outside
  experience/ability
Unit cohesion (general 0.11              (0.03–0.20)b       0.01 (20.12, 0.15)b        0.25 (0.15–0.36)b          NS              ,0.05c        ,0.05c
  factor)
Time (days) between 532.5                (490.7–574.3)b 515.3 (478.7–551.9)b 729.4 (693.7–765.1)b NSc                             ,0.001c       ,0.001c
  leaving theatre and
  completing
  questionnaire

Numbers (n), percentages (%), means (M) and 95% CIs are displayed together with P values for t-tests and x2 statistics. NS 5 not significant.
a
    Some categories do not add up to denominators because of missing data.
b
    Mean and 95% CI and corresponding t-test.
c
t-test adjusted for unequal variances.

childhood adversity also had a smaller effect on PARAs                                 There is some evidence of low rates of PTSD in para-
compared to the INF for symptoms of common mental dis-                              troopers [4] but the lack of a control group in that study
order. However, PARAs were equally reactive to INF and                              limits the conclusions that can be drawn. The present
RMCs regarding coming under small arms fire, coming un-                             study showed that PARAs had similar rates of symptoms
der mortar or artillery fire and thinking they might be killed.                     of PTSD compared with the INF.
   These results fit with previous research that has com-                              The RMCs had fewer pre-deployment risk factors
pared mental health outcomes between US marines and                                 compared with the INF, with higher levels of education
other troops. Studies have shown that combat-deployed                               and lower rates of childhood adversity. Previous studies
marines had lower rates of psychiatric disorders com-                               have shown that high levels of childhood adversity
pared to both non-deployed marines and navy personnel                               increase the risk of developing PTSD symptoms
[6] and that marines report fewer mental health, family                             [14,23,24] and other mental health problems, such as de-
and alcohol problems compared to army soldiers [5].                                 pression and anxiety, in military populations [25]. A US
However, in the present study, alcohol problems were                                study of marines who had deployed to Iraq or Afghanistan
comparable between the three groups.                                                showed that marines who had higher levels of education,
   In contrast, a recent report of psychiatric morbidity                            measured as some college or a college degree, were at
among the UK armed forces [22] showed that RMCs                                     lower risk of screening positive for PTSD [26].
had lower rates of any mental illness compared with                                    The lower rates of mental ill-health in RMCs may also
the other services, but the rates of PTSD were higher                               be a result of stigma. Research on stigma in the military
among RMCs. However, these analyses were not adjusted                               has shown that it is more prevalent among individuals
for covariates, and young age, female gender and deploy-                            who experience mental health problems [27]. Concerns
ments to Iraq or Afghanistan were also shown to be pre-                             regarding disclosure of psychiatric difficulties include be-
dictors of PTSD and mental illness.                                                 ing perceived as weak and not being trusted by peers [28].
J. SUNDIN ET AL.: MENTAL HEALTH IN MILITARY PERSONNEL 557

Table 4. Unadjusted prevalence and logistic regression models comparing the PARAs and RMCs with other Army infantry (INF) on adverse
health outcomes

                                                                        Cases, n (%)       Unadjusted OR (95% CI)               Adjusted OR (95% CI)          N

GHQ                                                      INF            132   (24)
                                                         PARAs           36   (18)         0.73 (0.48–1.09)                     0.81 (0.51–1.27)a             728
                                                         RMCs            34   (13)         0.46 (0.31–0.70)                     0.58 (0.36–0.93)b             659
Fatigue                                                  INF            207   (37)
                                                         PARAs           48   (25)         0.55 (0.38–0.80)                     0.51 (0.34–0.78)c             721
                                                         RMCs            66   (24)         0.55 (0.40–0.76)                     0.62 (0.43–0.89)d             811
Alcohol use disorders identification test                INF            147   (26)
                                                         PARAs           59   (30)         1.24 (0.87–1.78)                     1.31 (0.85–2.02)e             630
                                                         RMCs            72   (26)         1.02 (0.73–1.41)                     1.38 (0.95–2.02)f             826
Physical symptoms                                        INF             92   (16)
                                                         PARAs           16   (8)          0.45 (0.26–0.78)                     0.40 (0.22–0.72)g             727
                                                         RMCs            19   (7)          0.39 (0.23–0.65)                     0.36 (0.20–0.64)h             798

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Number of cases (n), percentages (%), OR, 95% CIs are displayed together with numbers for the adjusted models (N).
a
    Adjusted for age, rank, childhood adversity, theatre of deployment, coming under small arms fire and unit cohesion.
b
    Adjusted for age, rank, childhood adversity, theatre of deployment, perception of work in theatre and unit cohesion.
c
    Adjusted for rank, childhood adversity, theatre of deployment, thought might be killed and unit cohesion.
d
    Adjusted for childhood adversity, theatre of deployment and unit cohesion.
e
 Adjusted for age, childhood adversity, time deployed for in past 3 years, theatre of deployment, unit cohesion and time between leaving theatre and completing the
questionnaire.
f
    Adjusted for age, rank, childhood adversity and theatre of deployment.
g
    Adjusted for rank, time deployed for in past 3 years, theatre of deployment, saw personnel wounded or killed and unit cohesion.
h
    Adjusted for rank, childhood adversity, time deployed for in past 3 years, theatre of deployment, saw personnel wounded or killed and unit cohesion.

Table 5. Negative binomial regression models of PCL-C scores in                         the UK MOD and that all personal information would
the paratroopers (PARAs) and RMCs compared with other INF and                           be kept completely confidential.
comparing the PARAs and RMCs                                                               Previous research has also suggested that the lower lev-
                                                                                        els of PTSD symptom severity in RMCs is likely to be due
PCL-C Cases, n (%) Unadjusted IRR                     Adjusted IRR              N       to higher levels of group cohesion, fitness and general mo-
                                                                                        tivation [3]. While RMCs had higher levels of unit cohe-
INF   36 (6)                                                                            sion, there was no difference between PARAs and the
PARAs 12 (6)                   0.75 (0.58–0.96) 0.91 (0.70–1.18)a 622
                                                                                        INF. This may explain why there were no differences
RMCs   7 (3)                   0.54 (0.43–0.67) 0.64 (0.52–0.79)b 800
PARAs 12 (6)                                                                            in general mental health problems or PCL scores between
RMCs   7 (3)                   0.72 (0.52–1.00) 0.69 (0.49–0.98)c 456                   PARAs and the INF.
                                                                                           This study was based on data from a representative co-
Number of cases (n), percentages (%), IRR, and 95% CIs are displayed together
                                                                                        hort with a good response rate (61%) and we have shown
with numbers for the final models (N).                                                  that response was not linked to health outcome [12,29],
a
 Adjusted for rank, childhood adversity, theatre of deployment, coming under            which suggests that response bias was unlikely. The study
small arms fire, thought might be killed, unit cohesion and time between leaving        was limited by the data collected in the larger cohort study
theatre and completing the questionnaire.
                                                                                        and therefore differences in the selection and training be-
b
 Adjusted for rank, childhood adversity, theatre of deployment, coming under            tween the groups could not be assessed. Future research
small arms fire, saw personnel wounded or killed and unit cohesion.
c
                                                                                        can expand on this study by examining these factors. The
  Adjusted for childhood adversity, time deployed for in past 3 years, theatre of de-
ployment, time spent in a forward area, saw personnel wounded or killed and unit
                                                                                        cross-sectional nature of this study means that caution
cohesion.                                                                               should be exercised on the interpretation of the findings.
                                                                                        All health outcomes were assessed with screening meas-
                                                                                        ures and represent probable mental illness, except for
Fear of a harmful effect on one’s career may lead to fewer                              PTSD that was measured as PCL-C score.
disclosures of poor health in RMC and PARA personnel,                                      A sensitivity analysis was carried out on only TELIC-
who by the nature of their training and culture are more                                deployed personnel, and the results support that the dif-
likely to favour resilience than regular troops. However,                               ferences in health outcomes between the RMCs and
during recruitment for the study, all participants were in-                             PARAs compared to the INF were not due to the theatre
formed that the study was conducted independently of                                    of deployment.
558 OCCUPATIONAL MEDICINE

   We consider that our findings show that the effect of            orary Civilian Consultant Advisor in Psychiatry to the British
warfare on troops’ well-being is not universal across oc-           Army and a Trustee of Combat Stress, a UK charity that pro-
cupational groups. Both PARAs and RMCs had fewer                    vides services and support for veterans with mental health prob-
physical symptoms and were less fatigued compared with              lems. All the other authors declare that they have no conflict of
                                                                    interests.
the INF, and RMCs were also less likely to have general
mental health problems and had lower PCL-C scores.
This effect appears to be independent of combat exposure
and socio-demographic differences. A possible explanation           References
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